Abstract

Viet Nam has increasing internal migration since the Renovation (Doi Moi) in 1986. Migration flows – particularly rural-to-urban migration – have positive and negative effects to migrants, their family, and socio-economics in their places of origin and of destination. On the one hand, migration is an opportunity for improving wages of migrants, for ensuring economic security of their family, and for contributing to social and economic developments of the country. On the other hand, migration bears risks to migrants – especially health-related risks – and pressures on infrastructure development and social services at destinations. Many studies on health issues of migrants suggested that rural-to-urban migrants are more vulnerable to ill-health and have less access to health services than non-migrants. However, studies up to date did not use population-based and comparative approaches between migrant and non-migrant populations nor validated study tools. The studies of this dissertation examined the health status of non-migrants and 03 groups of rural-to-urban migrants: migrants working in industrial zones (IZ), migrants working in private small enterprise (PSE), and seasonal migrants. In addition, studies have assessed the access to health services and identified barriers to the access of migrants. The dissertation used a mixed qualitative-quantitative approach in four subsequent study phases. Phase 1 analyzed secondary data from the 1989, 1999, and 2009 national censuses to characterize trends and patterns of rural-to-urban migration in Viet Nam. We could show that inter-provincial migration flows have changed dramatically over time. There was an increase in relative and absolute migration flows, an inversion of the male-female ratio with higher proportions of women in 2009 than in previous years, and a decrease in the average age of migrants. We could also confirm the relationship between migration and provincial socio-economic status (i.e. monthly income per capita) and urbanization (i.e. proportion of urban population). These findings reflect an unequally growing labor market in Vietnamese provinces. The increase of migration flows challenges the national health system to ensure access to health care services and health insurances, as well as to develop health services adapted to these populations. In Phase 2 we have evaluated the health status of migrants by using the Short Form 36 version 2 (SF-36v2). The SF-36v2 is a validated and widely used health status assessment form. In this phase, we have also compared health status and the access to health services of migrants with those of non-migrants. Findings confirmed the reliability of the Vietnamese SF-36v2. Findings also showed that seasonal migrants were more likely to have physical ill-health than other groups, while migrants working in IZ were more likely to have mental ill-health than non-migrants and other migrant populations. Health insurance registration was an important factor related to the utilization of health care services and migrants were less likely to use health services than non-migrants in the same municipalities. Among migrant populations, seasonal migrants had the lowest health service utilization frequency. Indeed, low income is the main obstacle of the utilization of health care services for seasonal migrants. The outcomes of this are that they pay less attention to their health, attend in available health programs at the destination, and are less health care insured. These, in return, encourage self-treatment of seasonal migrants. Findings from Phase 1 and Phase 2 also showed that female migrants accounted for the highest proportion of the whole migrant population. They faced many health risks, particularly reproductive health of female migrants working in IZ. Phase 3, therefore, focused on the evaluation of access to health services for reproductive tract infections (RTIs) among female migrants working in IZ. Findings of this phase showed that health insurance was an important factor influencing the utilization of health services, but also social-cultural factors such as traditional norms – that integrate reproductive health problems with sexual relationship. The latter led to shame of female migrants to seek health services for RTIs and other reproductive health services. Finally, in Phase 4, we have designed an intervention proposal for improved utilization of reproductive health services for female migrants aged 18-49 working in IZ in Viet Nam. This intervention program will use available resources and should increase health insurance coverage and their application to reproductive health care services of female migrants. It also aims to increase knowledge of these health issues and possibilities of the access to health care services of female migrants. Based on the findings of my dissertation, I could formulate recommendations for future interventions and research, for policy makers, health service providers at destination, employers of migrants, and migrants. Briefly, policy makers should recognize that migrants are vulnerable to ill-health, including both physical and mental health. For specific interventions such as reproductive health (e.g. RTIs) they are a priority group. Health service providers should integrate adapted health programs for migrants into their routine health programs, for example, periodic gynaecological examination programs, expanded program on immunization (EPI), and other health promotion programs – which better ensures sustainability of intervention programs. Employers should comply with laws of social and health insurance for employees, especially migrant employees. Moreover, they should strengthen the capacity of their health care units and collaborate with local health systems to provide health care services to migrant employees. Finally, migrants should register for temporary residence at the destination because this will provide them rights in accessing social and health services. Also, they should have knowledge about benefits of health insurance and available kinds of health insurances. Migrants should have better access to health promotion programs and pay more attention to their health.